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DIABETES MELLITUS
ARRANGED BY:
Department of Internist
Islamic Hospital of Jakarta, Cempaka Putih
Medical Faculty of Muhammadiyah Jakarta University
Period July 3th 2017-July 30th 2017
SUBJECTIVE (S)
Patient’s Identity
• Name : Mr. S
• Age : 39th years old
• Address : St. Rusun Jati Rawasari Cempaka Putih
• Religion : Moslem
• Occupation : Private employees
• Marital status : Married
• Education : Senior High School
• Date of admission : July,7th 2017
• MR. Number : 00970907
SUBJECTIVE (S)
Chief Complaint
Tingling in both legs since 1 week before entering the hospital.
Additional Complaints
The patient feels dizzy and both of his feet felt pain.
History of Present Illness
History of Family
• None of his family has same problem
• His mother had history of hypertension
• No history of diabetes mellitus
• No history of cardiovascular disease
• No history of respiratory disease
History of Allergy
• Patient has no allergy of food, drugs and weather.
History of Treatment
• Patient have not taken any medications to reduce his
glucose, but patients only drink some rifampicin,
isoniazid, pyrazinamide and ethambutol drugs for the
treatment of tuberculosis
History of Psychosocial
• Patient said that he often ate sweet foods and more than
3 times a day. Patient smoked but did not drink alcohol.
OBJECTIVE (O)
PHYSICAL EXAMINATION
General Status : Mild ill
Consciousness : Composmentis
Vital Sign
BP : 120/80 mmHg RR : 18x/mnt
HR : 76x/mnt Suhu : 36,9 ◦ C
Anthropometric Status
Body Weight: 50 kg
Body High: 163 cm
BMI : 18,83 kg/m2
GENERAL PHYSICAL EXAMINATION
Head : Normocephal, deformity (-)
Thoraks :
Inspection : the movement of the chest symmetrical
Palpation : vocal fremitus is same in dextra and sinistra
Percussion : Sonor
Auscultacion : vesicular breath sounds + / +, ronkhi - / -, wheezing - / -
GENERAL PHYSICAL EXAMINATION
Heart :
Inspection : ictus cordis not seen
Palpation : ictus cordis not palpable
Percussion : Right heart margin: sternalis line sinistra ICS-V
left heart margin: midclavicula line sinistra ICS-V.
Auscultation : Regular 1st & 2nd heart sounds, murmur (-), gallop (-)
Abdomen :
Inspection : looked flat
Auscultation : bowel (+) sounds, 7x/minutes
Palpation : pressure pain (-), ascites (-)
Percussion : timpani, shifting dullness (-)
GENERAL PHYSICAL EXAMINATION
Extremities:
Superior : Edema (- / -), warm akral(+ / +), RCT <2 seconds (+ / +)
Inferior : Edema (-/ -), warm akral (+ / +), RCT <2 seconds (+ / +)
LABORATORY EXAMINATION
Date 05/07/2017
Resume
Mr. S, 39th years old, came with complaints of continuous
tingling in both legs. In the night frequent urination and often feel
thirsty. He was losing weight, but he had a good appetite and ate a
lot. His body felt weak and his head felt dizzy. Patient was currently
in the second month of tuberculosis treatment. The patient did not
know that he had diabetes mellitus before, and he had just know
that his glucose test is high. Patient liked to eating the sweet foods.
Physical examination : BP: 120/60 mmHg, HR: 76x/minute,
RR: 18x/minute, Temp : 36.9° C.
Laboratory examination: Plasma glucose : 610 mg/dL, BTA:
Positive (+).
PROBLEM LIST
• Diabetes mellitus
• Tuberculosis
ASSESMENT (A)
Diabetes Mellitus
S : Tingling in both legs continuously. In the night
frequent urination and often feel thirsty. Weight loss, but
he has a good appetite and ate a lot. The body feels gold
and head feels dizzy.
O : BP: 120/80 mmHg, HR: 76x/minute, RR: 18x/minute,
Temp : 36.9° C.
Plasma glucose: 610 mg/dL
A : Diabetes mellitus
P : Turning his lifestyles
Check and control the glucose
Humalog mix quick pen 12 IU/ml 2 x 1 ac
ASSESMENT (A)
Tuberculosis
S : Cough for more than 2 weeks, sweating in the
night, weight loss, and body felt weak.
O : BP: 120/80 mmHg, HR: 76x/minute, RR:
18x/minute, Temp : 36.9° C.
BTA : Positif (+)
A : Tuberculosis
P : Rifampicin 450 mg 1x1
Isoniazid 300 mg 1x1
Pyrazinamid 500 mg 1x2
Etambutol 500 mg 1x2
PROGNOSIS
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanationam : malam
LITERATURE REVIEW
DIABETES MELLITUS
DEFINITION